Gastrointestinal calcium absorption and dietary calcium load: relationships with bone remodelling in vertebral osteoporosis

Hypocalciuria as a Predictor of Reduced Intestinal Calcium Absorption

Impaired intestinal calcium absorption contributes to osteoporosis, but its measurement is limited to research settings. We hypothesized that 24-hour urine calcium (24HUC) values could diagnose low fractional calcium absorption (FCA). We performed a post hoc analysis of clinical trial data to determine whether 24HUC predicted low FCA compared with the gold standard dual calcium isotope method. Two hundred thirty postmenopausal women <75 years old without osteoporosis underwent 445 FCA measurements using calcium isotopes (8 mg of oral ⁴⁴Ca, 3 mg of intravenous ⁴²Ca) and a 24-hour inpatient urine collection at 0 and 12 months. We determined subjects’ total calcium intake via review of food diaries and supplements. Net calcium absorption (NCA) was total calcium intake × FCA. NCA and 24HUC values demonstrated a positive correlation (r = 0.34; 95% confidence interval, 0.25 to 0.42; P < 0.001). We calculated sensitivity, specificity, positive (PPV) and negative predictive value (NPV) for the ability of 24HUC thresholds to predict calcium malabsorption. When low calcium absorption was defined as <120 mg/d, a 24HUC value <150 mg demonstrated 65% sensitivity, 67% specificity, 31% PPV, and 89% NPV. When calcium malabsorption was defined as <100 mg/d, a 24HUC value <150 mg demonstrated 72% sensitivity, 65% specificity, 22% PPV, and 94% NPV. A 24HUC value <150 mg demonstrated a high NPV for calcium malabsorption. We suggest that 24HUC levels can exclude calcium malabsorption in postmenopausal women.

Factors associated with calcium absorption in postmenopausal women: a post hoc analysis of dual-isotope studies

Reduced calcium absorption is a risk factor for osteoporosis. This study examined factors associated with fractional calcium absorption (FCA) and net calcium absorption in postmenopausal women in a post hoc analysis of three completed dual-isotope studies. Data were analyzed from 50 postmenopausal women undergoing 121 inpatient research visits in three studies evaluating changes in FCA related to correction of vitamin D insufficiency (n=19), use of proton pump inhibitors (n=21), and use of aromatase inhibitors to treat breast cancer (n=10). Net calcium absorption was the product of FCA and total calcium intake in milligrams per day. Variables included subjects' age, race, body mass index, serum calcium, creatinine, parathyroid hormone, 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D, and habitual intake of kilocalories, protein, fat, carbohydrate, fiber, calcium, iron, magnesium, oxalate, phosphorus, potassium, and vitamin D based on outpatient diet diaries. In multivariate models, subjects' age, dietary intake of kilocalories, carbohydrates, fat, fiber, calcium, and potassium were significant predictors of FCA. In multiple variable models predicting net calcium absorption, dietary intake of kilocalories, fat, fiber, calcium, potassium, and serum 1,25-dihydroxyvitamin D were significant. The square of the correlation between actual and predicted values (an approximation of R(2)) was 0.748 for FCA and 0.726 for net calcium absorption. Similar to other studies, this study found that age, 1,25-dihydroxyvitamin D, and dietary calcium and fat were associated with calcium absorption. Dietary intake of kilocalories, carbohydrates, and potassium were new factors that were significantly associated with FCA and net calcium absorption. In summary, the study suggests that several dietary habits play a role in calcium absorption, beyond vitamin D and calcium.

Vitamin D insufficiency: disease or no disease?

Vitamin D insufficiency (VDI) is widely reported. In patients with normal PTH, the diagnosis rests on increases in fractional calcium absorption (FCA) when 25(OH)D increases above 30 ng/ml. However, estimates of increased FCA after correction of VDI vary dramatically, depending on study methods. We used a dual stable calcium isotope to clarify the impact of vitamin D repletion on FCA in postmenopausal women with VDI. We hypothesized that FCA would increase with vitamin D repletion. We studied postmenopausal women with VDI [25(OH)D = 16-24 ng/ml] and an estimated calcium intake <or=1100 mg daily. Exclusion criteria included hypercalcemia, hypercalciuria, renal insufficiency, nephrolithiasis, gastrointestinal disorders, osteomalacia, prior adult fragility fracture, baseline T-score < -3.0, and use of medications known to interfere with vitamin D or calcium metabolism. Each woman underwent inpatient FCA studies before and after correction of VDI. We used ergocalciferol 50,000 IU/d for 15 days to achieve vitamin D repletion. During each study, women consumed their typical diet. They ingested (44)Ca orally with breakfast and received (42)Ca intravenously. We collected urine for 24 h and measured its calcium isotope content by mass spectrometry. Eighteen women completed the study; all but two had normal PTH. During the first and second FCA studies, their mean 25(OH)D level was 22 +/- 4 and 64 +/- 21 ng/ml, respectively (p < 0.001). Subjects' average FCA was 24 +/- 7% initially and 27 +/- 6% after vitamin D repletion (p = 0.04). Thus, FCA increased by 3 +/- 1% with correction of VDI. Postmenopausal women with VDI experience small FCA increments with vitamin D therapy. In existing literature, this small change in FCA does not associate with lower fracture rates or consistently higher bone mass. Future studies should ascertain whether small FCA increments favorably affect the skeleton.

Ovariectomized murine model of postmenopausal calcium malabsorption

Two experiments were carried out to examine whether the ovariectomized mouse is a potential in vivo model of intestinal calcium malabsorption as occurs in postmenopausal osteoporosis. In the first experiment, we compared the effects of ovariectomy and 17 beta-estradiol (E2) therapy on calcium absorption in C3H/HeJ (C3H) and C57BL/6J (C57BL) mice, which have high and low peak bone mass, respectively. For each strain of mice, three groups were studied: sham operated, ovariectomized, (OVX), and OVX + E2 (60 micrograms/kg of body weight [bw]/day). Therapy was continued for 35 days and calcium absorption measured. In the C3H mice, ovariectomy caused an increase in fecal calcium (17.6%), and a decrease in the amount (12.8%) and percentage (12.5%) of calcium absorbed. The decrease was prevented by E2 therapy, but the differences in the calcium absorption parameters among the groups were not statistically significant. In contrast, in the C57BL mice, ovariectomy caused a marked increase in fecal calcium (84.5%, p < 0.01), and a marked decrease in the amount (55%, p < 0.01) and percentage (34.8%, p < 0.001) of calcium absorbed, and the decrease in the percentage of calcium absorbed was partially prevented by E2 therapy (p < 0.05). In experiment 2, a dose-response study of the effects of E2 therapy on calcium absorption in OVX C57BL mice was carried out. Five groups of mice were studied: Group 1, sham operated; Group 2, OVX; Group 3, OVX + 60 micrograms of E2/kg of bw/day; Group 4, OVX + 120 micrograms of E2/kg of bw/day; Group 5, OVX + 240 micrograms of E2/kg of bw/day. Therapy was continued for 28 days and calcium absorption measured. Ovariectomy caused a marked increase in fecal calcium (50%, p < 0.0001) and urinary calcium (31%, p < 0.0001) and a marked decrease in calcium absorption (44.9%, p < 0.0001), and these changes were prevented by E2 therapy. The highest level of calcium absorption (109%, p < 0.0001, vs. OVX) was observed in the 120 micrograms of E2 group. Ovariectomy and E2 slightly increased plasma 1,25-dihydroxyvitamin D (1,25(OH)2D) levels but there was no significant correlation between 1,25(OH)2D levels and calcium absorption. The findings in the C57BL mice suggest that estrogen is a physiological regulator of calcium absorption in this strain of mice. Furthermore, these findings share many characteristics with intestinal calcium malabsorption and its reversal by estrogen therapy in hypoestrogenic women. We propose that the OVX C57BL mice warrants further characterization as a potential animal model for investigating issues related to calcium malabsorption in postmenopausal women.

The effect of oophorectomy on calcium homeostasis

Postmenopausal bone loss is associated with a rise in the fasting urine calcium excretion which has been proposed to be a possible cause of increased bone resorption. The oophorectomized rat is widely used as a model of postmenopausal bone loss, but preliminary data suggest that urine calcium excretion is not increased following oophorectomy in this animal model. However the present detailed experimental protocol demonstrated that oophorectomy in adult rats increased the obligatory urine calcium excretion compared with ovary-intact rats (P < 0.001). Importantly urine hydroxyproline excretion was positively correlated with urine calcium only in the oophorectomized rats (P = 0.003). This urine calcium was positively correlated with urine phosphate excretion when dietary sodium was low (P < 0.001) and with urine sodium excretion when dietary sodium was elevated (P = 0.003). Calcium balance studies indicated a greater fall in calcium accretion in growing, oophorectomized rats (6 to 15 weeks of age) compared with ovary-intact animals and intestinal calcium secretion was the major component of the calcium balance to be affected. Losses of calcium in the urine were relatively minor in these growing rats.